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    v1.0.28
    OpenPayerPolicy UpdatesReimbursement/Payment PolicyIndiana IHCP Renal Dialysis Coverage | OpenPayer
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    CurrentIndiana Department of InsurancePolicy PROMOD00045

    Renal Dialysis Services

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    This policy governs IHCP fee-for-service coverage, reimbursement, coding, and billing requirements for hemodialysis and peritoneal dialysis services in hospital outpatient settings, freestanding renal dialysis clinics, and patients' homes.

    Policy Summary
    PayerIndiana Department of Insurance
    PolicyRenal Dialysis Services
    Policy CodePolicy PROMOD00045
    Change TypeClarification and administrative updateno material coverage change
    Effective DateNov 1, 2025
    Next Review DateNot specified
    Key ActionBill only one dialysis composite-rate revenue code and one unit per date of service; span dates are not allowed.
    SourceLink
    POLICY UPDATE CHANGES

    Version 8.0 edited text for clarity.

    Version 8.0 added Indiana PathWays for Aging to the initial note describing managed care services.

    10Dialysis session revenue codes listed
    1Maximum composite-rate revenue codes per date
    1Maximum units per date
    4Epoetin-related codes identified

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    13
    Hemoglobin threshold

    Dialysis Coverage Criteria

    Dialysis composite-rate coverage

    Routine hemodialysis and peritoneal dialysis are reimbursed through the composite rate when provided in an eligible setting and billed under the applicable dialysis revenue-code and date-of-service limits.

    ALL of the following

    • Service is routine hemodialysis or peritoneal dialysis provided in a hospital outpatient setting, freestanding renal dialysis clinic, or the patient's home.
    • Service is billed using an applicable dialysis composite-rate revenue code on an institutional claim.
    • Routine dialysis services are covered under the dialysis composite rate.

    ALL of the following

    • More than one dialysis composite-rate revenue code is billed for the same date of service.
    • The claim denies with EOB 6311.

    ALL of the following

    • More than one unit is billed for a dialysis composite-rate revenue code on the same date of service.
    • The claim is cut back to one unit and posts with EOB 4020.

    ALL of the following

    • Revenue code 881 is billed for miscellaneous dialysis or ultrafiltration.
    • No other dialysis service was provided on that date of service.
    • The service is reimbursable only under those circumstances.

    Equipment and supplies

    Uncommon supplies may be separately reimbursed only when they are outside the composite rate and meet the renal-diagnosis, dialysis-relatedness, and coding requirements.

    ALL of the following

    • Supply is a durable or disposable item or medical supply necessary for the effective performance of dialysis and is included in the composite rate.
    • The supply is not separately reimbursed.

    ALL of the following

    • Supply is uncommon and not included in the dialysis composite rate.
    • Revenue code 270 is billed with the appropriate procedure code.
    • The member has a qualifying renal diagnosis listed for renal dialysis services.

    Laboratory services

    Routine laboratory services associated with dialysis are included in the composite rate. Nonroutine services may be covered separately only when medical necessity is established and the required coding and documentation are submitted.

    ALL of the following

    • Laboratory service is routine and associated with hemodialysis or peritoneal dialysis.
    • The laboratory charge is included in the composite rate and is not separately billable.

    ALL of the following

    • Laboratory service is nonroutine.
    • The service is medically necessary and medical justification is indicated.
    • The service is billed with revenue code category 30X, the appropriate HCPCS code, and modifier AY, except that modifier AY is not required on Medicare crossover claims.

    Drugs and biologicals

    Certain injectable drugs and biologicals are included in the dialysis composite rate. Non-included products and specified epoetin administrations may be separately reimbursable when the stated identification, setting, and clinical requirements are met.

    ALL of the following

    • Drug or biological is one of the injectable drugs or biologicals included in the dialysis composite rate.
    • The charge is not separately reimbursed.

    ALL of the following

    • Drug or biological is not included in the composite rate and requires specific identification.
    • Revenue code 636 is reported with the appropriate procedure code identifying the specific drug injected.

    Coding and Billing Codes

    Type-of-bill codesRevenueCovered
    131Outpatient hospital renal dialysis facilities
    721Freestanding renal dialysis clinics
    111Inpatient renal dialysis services
    Dialysis session revenue codesRevenueCovered
    820Hemodialysis, outpatient or home, general; use only when a more specific code is inappropriate
    821Hemodialysis, outpatient or home, composite or other rate
    823Hemodialysis, outpatient or home, home equipment
    825Hemodialysis, outpatient or home, support services
    829Hemodialysis, outpatient or home, other outpatient hemodialysis
    830Peritoneal dialysis, outpatient or home, general
    831Peritoneal dialysis, outpatient or home, peritoneal/composite or other rate
    841Continuous ambulatory peritoneal dialysis (CAPD), composite or other rate
    851Continuous cycling peritoneal dialysis (CCPD), composite or other rate
    881Miscellaneous dialysis, ultrafiltration; payable only when no other dialysis service was provided that date
    Dialysis suppliesRevenueCovered
    270Medical/surgical supplies and devices—general; for uncommon supplies not included in the composite rate
    Separately billed nonroutine laboratory servicesmixedCovered
    30XLaboratory services
    AYItem or service furnished to an ESRD patient that is not for the treatment of ESRD
    Drugs and biologicals requiring detailed codingRevenueCovered
    636Drugs requiring detailed coding
    Epoetin productsHCPCSCovered
    J0882Injection, darbepoetin alfa, 1 mcg, for ESRD on dialysis
    J0887Injection, epoetin beta, 1 microgram, for ESRD on dialysis
    Q4081Injection, epoetin alfa, 100 units, for ESRD on dialysis
    Q5105Injection, epoetin alfa biosimilar (Retacrit), 100 units, for ESRD on dialysis
    Dialysis composite-rate revenue code limit
    Maximum composite-rate revenue codes1 per date of service
    Applies toDialysis composite-rate revenue codes
    Multiple codesClaims reporting more than one dialysis composite-rate revenue code for the same date of service deny with EOB 6311
    Dialysis composite-rate unit limit
    Maximum units1 unit per dialysis composite-rate revenue code per date of service
    Billing requirement

    Provider Billing Requirements

    Note

    Route Managed Care Services to the MCE

    For services provided through HIP, Hoosier Care Connect, Hoosier Healthwise, or Indiana PathWays for Aging, contact the member’s managed care entity (MCE) or refer to the applicable MCE provider manual. FFS information in this module does not apply to managed care services.

    • MCE contact information is available in the IHCP Quick Reference Guide at in.gov/medicaid/providers.
    Denial Risk

    Do Not Separately Bill Composite-Rate Services

    Do not separately bill services included in the dialysis composite rate when a dialysis composite-rate revenue code is billed for the same date of service. Such services may deny, or previously paid services may be recouped.

    • Same-claim services may deny with EOB 3317.
    • Services billed on a different claim may deny with EOB 6312.
    • Previously paid services may be recouped with EOB 6314; the composite-rate claim may post EOB 6313.

    Key Definitions

    End-stage renal disease (ESRD)
    ConditionA chronic condition
    Kidney impairmentKidney impairment considered irreversible
    PermanenceThe impairment is permanent
    Composite rate
    DefinitionA composite reimbursement rate for dialysis
    Operational and personnel servicesIncludes overhead costs, personnel services, and administrative services, including nursing staff members, social worker, and dietician
    Clinical and material servicesIncludes equipment and supplies, ESRD-related laboratory tests, and certain injectable drugs and biologicals
    Policy Summary
    PayerIndiana Department of Insurance
    PolicyRenal Dialysis Services
    Policy CodePolicy PROMOD00045
    Change TypeClarification and administrative updateno material coverage change
    Effective DateNov 1, 2025
    Next Review DateNot specified
    Key ActionBill only one dialysis composite-rate revenue code and one unit per date of service; span dates are not allowed.
    SourceLink
    On This Page
    Dialysis Coverage CriteriaCoding and Billing CodesProvider Billing RequirementsKey Definitions
  1. The supply is directly related to the dialysis service.
  2. The claim may be covered, subject to postpayment review and recoupment.

    3. ALL of the following

    • A supply revenue code is billed without a HCPCS surgical procedure code, or is billed with treatment-room revenue codes 45X, 48X, 51X, 52X, 70X, 71X, 72X, or 76X without a HCPCS surgical procedure code.
    • The supply claim is denied.
  3. The claim includes documentation showing that the service was not routine and was medically necessary.
  4. The service may be covered separately.

    5. ALL of the following

    • An allowable laboratory procedure is billed on the same date of service as a dialysis composite-rate revenue code.
    • The required medical-necessity attachment is not included.
    • The claim suspends with EOB 3318.

    ALL of the following

    • Laboratory services are performed in conjunction with the dialysis treatment.
    • The facility performing the dialysis treatment bills the laboratory services.
    • An independent laboratory does not bill the IHCP separately for those services.
    The number of units administered is reported.

    ALL of the following

    • Epoetin administration occurs in a hospital outpatient or renal dialysis treatment facility setting.
    • The member is receiving treatment for end-stage renal disease.
    • The member's hemoglobin level is less than 13.
    • The billed product is one of the specified HCPCS products: J0882, J0887, Q4081, or Q5105.
    • The epoetin administration may be covered, using the appropriate revenue code under national billing guidelines.
    Providers are limited to one unit of service per detail line for these codes
    Excess unitsClaims reporting more than one unit are cut back to one unit and post with EOB 4020
    Epoetin administration threshold
    Covered hemoglobin levelLess than 13
    Covered settingHospital outpatient or renal dialysis treatment facility
    Covered populationMembers receiving treatment for end-stage renal disease
    Billing Rule

    Use the Institutional Claim and Correct Type of Bill

    Submit renal dialysis claims on an institutional claim using the UB-04, IHCP Portal institutional claim, or 837I transaction, and use the type-of-bill code that matches the setting.

    • Outpatient hospital renal dialysis facility: type of bill 131.
    • Freestanding renal dialysis clinic: type of bill 721.
    • Inpatient renal dialysis services: type of bill 111.
    • Home-based dialysis: use the type-of-bill code normally used by the billing provider.
    • Use the applicable principal ICD diagnosis code listed in Renal Dialysis Services Codes.
    Billing Rule

    Report Each Service Date Separately

    Bill each date-specific service separately and report the specific service date on every detail line. This requirement applies to dialysis treatments and all other services provided during the month.

    • For example, 15 dialysis treatments require 15 detail lines, each reporting its service date.
    Denial Risk

    Limit Dialysis Sessions to One Code and Unit per Date

    Report no more than one dialysis composite-rate revenue code and one unit for each date of service. Span dates are not allowed for composite-rate revenue codes.

    • Applicable session revenue codes include 820, 821, 823, 825, 829, 830, 831, 841, 851, and 881.
    • Revenue code 820 is for use only when a more specific code is inappropriate.
    • Revenue code 881 is reimbursable only when no other dialysis service was provided on that date.
    • More than one composite-rate code may deny with EOB 6311.
    • Units above one may be cut back to one and post EOB 4020.
    • Use no more than one unit per detail line.
    Documentation Required

    Bill Uncommon Dialysis Supplies Only When Qualifying

    Use revenue code 270 with the appropriate procedure code only for uncommon supplies that are not included in the dialysis composite rate. Multiple units are permitted only when the member has a qualifying renal diagnosis and the supply is directly related to dialysis; payment is subject to postpayment review and recoupment.

    • Supply revenue code 270 is denied without a HCPCS surgical procedure code.
    • Supplies are not paid when billed with treatment-room revenue codes 45X, 48X, 51X, 52X, 70X, 71X, 72X, or 76X without a HCPCS surgical procedure code.
    Documentation Required

    Bill Separately Billed Laboratory Services Correctly

    Routine laboratory charges are included in the dialysis composite rate and cannot be billed separately. Nonroutine laboratory services may be billed separately when medically necessary and supported by documentation.

    • Use revenue code category 30X with the appropriate HCPCS code and modifier AY.
    • Include documentation showing that the service was nonroutine and medically necessary.
    • Allowable services billed on the same date as a composite-rate code may suspend with EOB 3318 pending medical-necessity documentation.
    • Modifier AY is not required on Medicare crossover claims.
    • The dialysis facility must bill laboratory services performed with the dialysis treatment; an independent laboratory cannot bill IHCP separately for those services.
    Billing Rule

    Use Detailed Drug Coding

    For drugs and biological products not included in the composite rate that require specific identification, report revenue code 636 with the appropriate procedure code and the number of units administered.

    • Use the procedure code that identifies the specific injected drug.
    • Confirm applicable procedure-code linkages in Revenue Codes With Special Procedure Code Linkages.
    Billing Rule

    Bill Epoetin Administration for Qualifying ESRD Members

    For members with ESRD, the IHCP covers administration of specified epoetin products in a hospital outpatient or renal dialysis treatment facility setting when the hemoglobin level is less than 13. Follow national billing guidelines for the revenue codes used with the applicable HCPCS codes.

    • Covered HCPCS products include J0882 (darbepoetin alfa), J0887 (epoetin beta), Q4081 (epoetin alfa), and Q5105 (epoetin alfa biosimilar, Retacrit).
    • Use the applicable product-specific units and revenue-code requirements.
    Billing Rule

    Bill Physician Dialysis Services on a Professional Claim

    For ESRD-related physician services, apply the same criteria and coding methodology used by Medicare. Bill renal dialysis management services on a professional claim.

    • Use the CMS-1500, IHCP Portal professional claim, or 837P electronic transaction.
    • Report the appropriate procedure codes for the physician services.